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目的:探讨华法林与丙戊酸镁联合使用导致出血高危因素的作用机制,为临床治疗中合理选择药物提供参考。方法:临床药师对二尖瓣机械瓣膜置换术后合并癫痫患者脑出血患者联合使用华法林和丙戊酸镁导致脑出血的抗癫痫药物治疗方案进行分析及调整:停用丙戊酸镁,换用左乙拉西坦0.25 g,po,bid,14 d后加量至0.5 g,po,bid进行抗癫痫治疗,并对患者实施药学监护。结果:患者住院20 d后,国际标准化比值(INR)控制在2.5~3.0之间,无癫痫症状发作,病情稳定出院。结论:左乙拉西坦与华法林相互作用较小,可与华法林联合使用。
Objective: To investigate the mechanism of warfarin and magnesium valproate in combination with high risk factors for bleeding, provide a reference for the rational choice of drugs in clinical treatment. Methods: The clinical pharmacist analyzed and adjusted the antiepileptic drug treatment regimen of combined warfarin and magnesium valproate induced cerebral hemorrhage in patients with intracerebral hemorrhage complicated with epilepsy after mitral valve replacement. After discontinuation of magnesium valproate, Switch to levetiracetam 0.25 g, po, bid, 14 d after the dose to 0.5 g, po, bid for anti-epileptic treatment, and the implementation of the patient’s pharmacy care. Results: After 20 days of hospitalization, the international standardized ratio (INR) was controlled between 2.5 and 3.0. No symptoms of epilepsy occurred and the condition was stable. CONCLUSION: Levetiracetam has less interaction with warfarin and may be used in combination with warfarin.